Medi-Cal Rx News
Medi-Cal Rx Update:
Implementation of Phase I, Wave III - Reinstatement of Prior Authorizations for 11 Drug Classes
The Department of Health Care Services (DHCS) has announced a proposed plan for reinstatement of claim edits and prior authorizations (PAs), as well as phasing out of the Transition Policy for Medi-Cal Rx. DHCS presented a three-phase plan that includes reinstatement of PAs for new start medications based upon drug classes. This approach allows providers to initiate PAs on a gradual basis while DHCS continues to grandfather prescriptions with historical claims or PAs.
On September 16, 2022, Phase I, Wave III of the Reinstatement Plan will go-live. Providers will be required to submit PAs for new start medications in the 11 identified drug classes below.
- Diuretics
- Lipotropics, including statins and omega-3 fatty acids
- Hypoglycemics, including glucagon
- Coronary vasodilators (nitrates and pulmonary arterial hypertension agents)
- Cardiovascular agents, including antiarrhythmics and inotropes
- Anticoagulants and antiplatelets
- Niacin, Vitamin B, and Vitamin C products
New prescriptions for beneficiaries 21 years of age and under, for medications within the 11 drug classes, are excluded. Specifically, new start prescriptions for children and youth within these 11 drug classes will not be subject to PA reinstatement.
For Medi-Cal Rx prescribers who currently fax in prior authorization (PA) requests, CoverMyMeds® allows you to submit an electronic PA (ePA) for drug/product requests to Medi-Cal Rx.
Please visit the Medi-Cal Rx CoverMyMeds Guide for more information.
For any questions regarding the implementation of Phase I, Wave III, please contact Medi-Cal Rx at (800) 977-2272 or CenCal Health Pharmacy Department at (805) 562-1080.
Reinstatement of Reject Code 88 & Postponement of Reject Code 80
What is Happening?
Effective July 22, 2022, Drug Utilization Review (DUR) claim edits will be reinstated. Specifically, claims will reject for National Council for Prescription Drug Programs (NCPDP) Reject Code 88 – Drug Utilization Review Reject Error for DUR alerts such as drug-drug interactions, high dose, early refill, etc.
Review Medi-Cal Rx billing guidelines in the NCPDP Reject Code 88 DUR Reference Guide to avoid or resolve claim rejections.
The Department of Health Care Services (DHCS) has elected to postpone implementation of the National Council for Prescription Drug Programs (NCPDP) Reject Code 80 - Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.
Claims submitted to Medi-Cal Rx will NOT be edited for a diagnosis code as planned to begin July 22, 2022. However, providers are reminded of their obligation to document the meeting of Code 1 restrictions and to keep that information readily available.
Please contact the Pharmacy Department with any questions at (805) 562-1080.
Medi-Cal Rx Resources & Contract Drug List
COVID-19 Treatment Resources
COVID-19 Treatment Resources
CenCal Health is dedicated to keeping our providers up to date with the most current information for the treatment of COVID-19. The provided information gives details on the use of the pharmacy benefit and medical benefit for COVID-19 treatment.
COVID-19 National Institutes of Health Guidelines
The following National Institutes of Health (NIH) COVID-19 Treatment Guidelines provide clinicians with evidence-based recommendations on the management of COVID-19 and are revised with the emerging, rapidly evolving COVID-19 treatment options: NIH COVID-19 Treatment Guidelines
Outpatient Treatment of COVID-19 as a Medi-Cal Rx Pharmacy Benefit
COVID-19 Oral Antiviral Treatments
- Nirmatrelvir/Ritonavir (Paxlovid)
Monoclonal Antibodies for Pre-Exposure Prophylaxis of COVID-19
- Tixagevimab packaged with Cilgavimab (Evusheld)
Monoclonal Antibodies to Treat Mild-to-Moderate COVID-19
COVID-19 monoclonal antibodies and oral antiviral treatments are currently being distributed by the Department of Health and Human Services (HHS). Providers can find public locations that have received shipments of the COVID-19 monoclonal antibodies and oral antiviral treatments via the COVID-19 Therapeutics Locator (arcgis.com). For California, see Distribution and Ordering of Anti-SARS-CoV-2 Therapeutics on the California Department of Public Health website.
Remdesivir (Veklury) for Outpatient Treatment of COVID-19
The Department of Health Care Services (DHCS) will reimburse Remdesivir (Veklury) as a pharmacy benefit when dispensed for use in nonhospitalized patients in accordance with Food and Drug Administration (FDA) approval or Emergency Use Authorization (EUA).
For more information on COVID-19 treatments, including product fact sheets and patient-facing communication, visit the California Department of Public Health’s COVID-19 Treatments page.
Medi-Cal Rx Find a Pharmacy Search Tool
https://medi-calrx.dhcs.ca.gov/home/find-a-pharmacy/
To ensure expedited access to COVID-19 treatment users can enter their location and see Medi-Cal-Rx enrolled pharmacies or mail order options in their area. The search results can be easily sorted and filtered to find a pharmacy that specifically fits the user preferences.
CenCal Health Medical Benefit Coverage
Infused therapeutics with appropriate procedure codes can be billed to CenCal Health on a medical claim once FDA-approved (i.e., remdesivir). Infused monoclonal antibodies are currently supplied free to providers by the federal government, CenCal Health will only reimburse the administration fees with the appropriate administration procedure code in accordance with FDA Emergency Use Agents (EUA). As infused therapeutic options become FDA-approved and supported by DHCS, NIH Treatment Guidelines, CenCal Health will be responsible for coverage if billed on a medical claim.
Treatment for COVID-19 is a dynamic space and CenCal Health will provide quarterly updates on treatments and resources. For any questions regarding COVID-19 treatment resources please contact MediCal Rx at (800) 977-2273 or CenCal Health Pharmacy Department at (805) 562-1080.